Sm-09-03-03 - association between smoking.pmd

Smoking and minimal–mild depressive symptomatology in heavy smokers Association between smoking and minimal–mild depressive symptomatology in heavy smokers Ana Moreno Coutiño,¹ Silvia Ruiz Velasco,² María Elena Medina-Mora Icaza3 severity of tobacco addiction (p= .025). Those with a bachelor’seducational level, had less depressive symptomatology (p= .025).
The World Health Organization (WHO) estimates that by the year The high frequency of depressive symptomatology and the protective 2020 tobacco addiction will be responsible for 10 million deaths, factor of schooling concur with findings reported in other studies.
seventy percent of which will occur in underdeveloped countries. On The better understanding of the characteristics of smokers with the other hand, depression affects about 121 million people different levels of tobacco consumption and depressive worldwide, and is projected to reach a second place in the ranking symptomatology is suggested. It is important to gain knowledge on of Disability Adjusted Life Years (DALYs) calculated for all ages and the particular characteristics of specific groups of smokers for the development of new treatments that can simultaneously treat smoking In Mexico, 14 million people are current smokers and 9.6 million addiction and depression, and can also help to norm criteria for are former smokers, according to the 2002 National Addictions Survey, and almost four million people are diagnosed with depression.
Both disorders are classified among the main causes of mortality Key words: Smoking, depression, sociodemographic characteristics.
and disability in Mexico. By gender, major depression in females isthe second most prevalent disorder. Two percent of the Mexicanpopulation (two million people) present at least one major depressive episode before reaching the age of 18. Several studies have foundan important link between depression and smoking. More recently, it La Organización Mundial de la Salud (OMS) estima que para el año was reported that the manifestation of depressive symptomatology 2020 la adicción al tabaco será responsable de 10 millones de predicts smoking addiction. Although the strong association between muertes, 70% de las cuales ocurrirá en los países subdesarrollados.
affective disorders and drug abuse has been documented, they are La mitad de los fumadores actuales, aproximadamente 650 millo- generally treated independently. For this reason, the need for integral nes de personas, morirá debido a una causa relacionada con el management of comorbid diseases has been highlighted.
consumo de tabaco. Por otro lado, actualmente la depresión afecta Little is known about specific populations of patients that a cerca de 121 millones de personas en el mundo, y se ha proyecta- simultaneously manifest both disorders, and more knowledge is do que para el año 2020 ocupará el segundo lugar en Años de Vida needed in order to design precise integral treatments for this kind of Ajustados por Discapacidad (AVAD) en todos los grupos de edad y patients, taking into consideration the gender, severity of depression en ambos sexos. En México, 14 millones de personas son fumado- res actuales y 9.6 millones son ex fumadores, según la Encuesta The aim of this study was to describe the association between Nacional de Adicciones (ENA) 2002, y casi cuatro millones de per- depressive symptoms, sociodemographic characteristics, and pattern sonas padecen depresión. Ambos trastornos se clasifican entre las of tobacco consumption of heavy smokers with minimal-mild principales causas de morbimortalidad en nuestro país. En cuanto a depressive symptomatology in order to adjust for these relations in a las diferencias por sexo, en las mujeres, la depresión es el segundo later longitudinal regression analysis after these subjects have been trastorno más frecuente. El dos por ciento de la población mexicana assigned to different conditions of a new integral treatment to quit (dos millones de personas) ha padecido por lo menos un episodio de smoking. A total of 89 heavy smokers were assessed; 74 of them depresión importante antes de alcanzar la edad de 18 años. Varios (83%) had minimal-mild depressive symptomatology; there were 35 estudios han encontrado una asociación importante entre la depre- females and 39 males, with an average age of 44.3 yrs. Level of sión y el tabaquismo. Recientemente se reportó que la manifestación tobacco addiction was determined by the Fagerström Test for Nicotine de la sintomatología depresiva predice la adicción al tabaco.
Dependence, and the Beck Depression Inventory was used to assess De acuerdo con varios estudios, se sabe que la nicotina reduce depressive symptomatology. By means of regression models, we la incidencia y la gravedad de los síntomas depresivos y que la found an increase of the depressive symptomatology related to the abstinencia del tabaco puede desencadenar síntomas depresivos, ¹ Facultad de Psicología, UNAM.
² Departamento de Probabilidad y Estadística. Instituto de Investigaciones en Matemáticas Aplicadas y Sistemas (IIMAS), UNAM, México.
3 Directora General. Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz. Calz. México-Xochimilco 101, San Lorenzo Huipulco, Tlalpan, 14370,México D.F.
Correspondencia: Dra. Ana Moreno Coutiño. Av. Universidad 3004, Col. Copilco-Universidad, Del. Coyoacán, 04510 México D.F. Tel. 5658 3911.
Fax.5658 3744. E-mail: moca99_99@yahoo.com Recibido: 3 de diciembre de 2008. Aceptado: 9 de febrero de 2009.
por lo que se ha sugerido que las personas con depresión fuman a mujeres y 39 hombres, con una media de edad de 44.3 años. El manera de automedicación contra la sintomatología depresiva.
nivel de adicción al tabaco fue determinado por la prueba de A pesar de que ha sido documentada la fuerte asociación entre Fagerström para la dependencia a la nicotina, y se usó el Inventario los trastornos afectivos y las adicciones, estos trastornos se atienden de Depresión de Beck para determinar el nivel de sintomatología generalmente de manera independiente. Por esta razón, se ha depresiva. Mediante un modelo de regresión, encontramos un subrayado la necesidad de generar tratamientos integrales para los aumento de la sintomatología depresiva relacionada con la gravedad de la dependencia al tabaco (p=.025). Aquellos con nivel de Hasta el momento, se sabe poco sobre poblaciones específicas enseñanza de licenciatura presentaron menos sintomatología de pacientes que de manera simultánea son adictos al tabaco y depresiva (p=.025). Los principales resultados de este estudio son padecen sintomatología depresiva, por lo se requiere de mayor la asociación significativa entre el nivel de dependencia al tabaco y entendimiento de sus características para diseñar tratamientos la sintomatología depresiva en fumadores fuertes. Tanto la alta integrales específicos para este tipo de pacientes. Para ello se debe incidencia de la sintomatología depresiva como el factor protector tomar en consideración el sexo, la gravedad de la depresión y el de la enseñanza concuerdan con los reportes de otros estudios con nivel de dependencia de la nicotina.
El objetivo del presente estudio fue describir la relación que Es importante conocer las características particulares de grupos existe entre los síntomas depresivos, las características específicos de fumadores para desarrollar nuevos tratamientos que sociodemográficas y el patrón de consumo de tabaco en fumadores pueden tratar simultáneamente la adicción al tabaco y la depresión, fuertes con sintomatología depresiva mínima leve para ajustar dichas así como para ayudar a normar criterios para su tratamiento. Se relaciones mediante un modelo de regresión longitudinal, en un sugiere continuar ahondando en el conocimiento de las características estudio posterior, donde los pacientes serán asignados a diversas de los fumadores con diversos niveles de consumo de tabaco y condiciones terapéuticas de un nuevo tratamiento integral contra el Un total de 89 fumadores fuertes fueron evaluados; 74 de ellos Palabras clave: Tabaquismo, depresión, características (83%) padecían sintomatología depresiva mínima leve; había 35 More recently, it was reported that the manifestation of depressive symptomatology predicts smoking Worldwide, tobacco addiction is one of the main causes of addiction.14 To determine the probability of substance abuse preventable morbi-mortality and low quality of life; and it co-occuring with affection disorders, a study found that is also responsible for five million deaths per year (one out the latter occurred before substance abuse or dependence of 10 adult deaths worldwide). Half of the current smokers, approximately 650 million people, will die due to a cause Some of the differences between genders have been related to tobacco consumption. If these tendencies persist addressed. Women smokers are two times more likely to by the year 2020, the World Health Organization (WHO) present depression symptomatology compared to non-smo- estimates that tobacco addiction will be responsible for 10 king women, and five times more likely than men, while million deaths, 70% of which will occur in underdeveloped men who smoke more than one pack a day are five times countries. On the other hand, depression affects about 121 more likely to manifest depression symptoms compared to million people worldwide, and is projected to reach a non-smoking men. Current and former smokers are more second place in the ranking of Disability Adjusted Life Years likely to present depression compared to those who have (DALYs) calculated for all ages and both sexes by the year 2020. Today, depression is already the second cause of Although the strong association between affective DALYs in the 15-44 age range for both sexes combined.1 disorders and drug abuse has been documented, they are In Mexico, 14 million people are current smokers and generally treated independently. For this reason, the need 9.6 million are former smokers, according to the National for integral management of comorbid diseases has been Addictions Survey,2 and almost four million people are diagnosed with depression. Both disorders are classified Based on several studies, we know that nicotine redu- among the main causes of mortality and disability.3 By ces both the incidence and severity of depressive gender, major depression in females is the second most symptoms19-23 and that tobacco abstinence can uncover prevalent disorder. Two percent of the Mexican population depressive symptoms.23 More specifically, when these (two million people) present at least one major depression appear during the sixth week and sixth month of abstinence episode before reaching the age of 18.4 The peaks of incidence reincidence in smoking is expected.24 This correlates with for major depression are approximately at 17, 32 and 65 years.5 results obtained among depressed patients undergoing Several studies have found an important link between treatment in which the acceptance of anti-tobacco therapy depression and smoking.6-12 Smokers with a history of depression tend to relapse into depression when trying to It has been proposed that people with depression smoke as a form of automedication against depressive Smoking and minimal–mild depressive symptomatology in heavy smokers symptomatology by using negative reinforcement.20,23,26 this data, information regarding their general pattern of This explains why, in order to counteract nicotine abstinence tobacco consumption was collected during the initial symptoms, the administration of antidepressive drugs, such interview. The Beck Depression Inventory (BDI) of 21 items as bupropion and nortriptiline, has positive results.27-32 was used to assess depressive symptomatology.34 The latter Little is known about specific populations of patients has been validated for its application among Mexicans, and that simultaneously manifest both disorders, and more the Spanish versions of both the FTND and the BDI have knowledge is needed in order to design precise integral been extensively used.35-39 Carbon monoxide (CO) treatments for this kind of patients, taking into exhalation level and a sample of urine were requested to consideration the gender, severity of depression and level corroborate smoking level. To measure the alveolar concentration of CO in exhalation in ppm (parts per million) In Mexico, prevalence reports for mild and moderate a Micro Medical, Micro CO detector, was used. A gas depressive symptomatology are 23% and 49%, respectively.5 chromatographic-mass spectrometric method was used for The aim of this study was to describe the association between the detection and quantification of cotinine in urine, taking depressive symptoms, sociodemographic characteristics, and in to account the deuterated internal standard, following pattern of tobacco consumption in order to adjust for these the method of Hutchinson et al.40 The analyses were relations in a later longitudinal regression analysis after extracted by liquid-liquid extraction coupled to subjects have been assigned to one of three different centrifugation and evaporation. The cut-off point for conditions of a new integral treatment.
cotinine to verify abstinence was 40ng/ml, since theequipment could not verify any lower than that. Thecalibration curve for cotinine was created from 1-10 000 ng/ml. All data were corrected by recovery efficiencies.
The information collected was captured in a data base for analysis by means of regression models using the Stata10 program, where the dependent variable was the score A total of 89 heavy smokers —which were Mexican members obtained in the Beck Depression Inventory and the of the university community, either students, academics independent variables were all the sociodemographic va- (researchers and lectureres), administrative (secretaries, riables. We used a stepwise procedure to find out the accountants and functionaries) or support employees independent variables that had a significant effect on the (watchmen and maintenance workers)— who attended after BDI, and included gender, age, and marital status.
being invited for treatment of tobacco addiction at the ClinicAgainst Addictions of the National Autonomous Universityof Mexico (UNAM) were assessed. Heavy smoking was defined as consuming more than 10 cigarettes per day.
Depressive symptomatology was found in 83 patients Table 1 shows the sociodemographic characteristics of the (93%). Minimal-mild symptoms were present in 74 patients 74 heavy smokers included in this study. It also describes (83%) and heavy depressive symptoms were found in nine the principal patterns of smoking and depressive patients (10%). For this study, 15 patients were excluded: symptomatology. In the whole population, the mean those with heavy depressive symptoms, three cocaine addicts, number of cigarettes consumed per day was 18 cigarettes two pregnant women and one patient with schizoid traits.
(SD 7.6); the age of first tobacco use was 15.46 years (SD The 74 heavy smokers with minimal-mild depressive 4.33), that for years smoking was 25.39 (SD 10.09), and the symptoms included in this study were 35 females (47.3%) level of nicotine dependence, according to the Fagerström and 39 males (52.7%), with an age average of 44.3 years test, was 4.73 points (SD 2.21), which corresponds to a moderate level of dependence. The median of the depressivesymptomatology according to the Beck Inventory was 8.99 points (SD 5.77), which corresponds to a minimal level ofdepression.
Psychologists trained in the rehabilitation of smokers The p value for categorical variables was calculated approached smokers through individual and group with Pearson’s χ² statistic, and continuous variables were invitations in diverse entities of the university and arranged, analyzed on a mean difference t-test. It is worth mentioning for those interested, an appointment for evaluation at the that both males (n=39) and females (n=35) included in the Clinic Against Addictions of the UNAM, between February study were similar in age, school level, working status, age of first cigarette, years smoking, level of nicotine The level of tobacco addiction was determined by the dependence, and depressive symptomatology. The only Fagerström Test for Nicotine Dependence (FTND).33 Besides differences found were in the marital status and the pattern Table 1. Characteristics of severe smokers by gender Table 2. Beck Depression Inventory and SociodemographicCharacteristics *significance to 5%, ** significance to 10%.
concordance with the results in studies performed with different groups of smokers,6-10,41 as well as the significant relation between the bachelor’s level of education and thedecrease in the Beck Depression Inventory score. Patients with of smoking behavior, with males reporting a significant bachelor’s school level were more than five points under those higher number of cigarettes per day.
with school level lower than high school. A tendency in the Results of the regression models are shown in table 2.
decrease of depressive symptomatology was also observed The results of statistically significant variables and the main in patients with post-graduate degrees, which was probably sociodemographic characteristics, such as gender, age and non-significant due to the size of the sample. These findings marital status, are reported. Variables, such as reasons for are similar to previous reports that state that education level smoking initiation, years consuming the current amount acts as a protective factor against tobacco addiction.42,43 of cigarettes, number of attempts to quit smoking, living In relation to working status, a marginal protector fac- and working with other smokers, level of carbon monoxide tor was found for those in the administrative area, in exhalation and cotinine urine level, did not reach compared to support employees. On average, the BDI scores of the first were almost three points below. This finding Nicotine dependence level was considered as a could be related to the connection between educational level continuous variable, and its effect represents a 0.68 increment and working status, since almost half of the support in Beck’s scale for each change of one unit in the level of employees had lower than high school educational level.
dependence in the Fagerström test, showing that nicotine Although the level of tobacco dependence and the dependence was a risk factor for depression. On the other increment of depressive symptomatology associated hand, bachelor’s school level and administrative working sta- significantly, this was not reflected in the variables of carbon tus are protective factors against depressive symptomatology.
monoxide and cotinine levels, maybe because the time forthe collection of the samples after smoking was not controlled.
In those variables where differences by gender were significant, such as marital status and number of cigarettesper day, models of regression were adjusted separately by The main findings of this study are the significant association gender and no significant differences were found. However, between the level of tobacco dependence and the increment most patients that consumed more than one pack of cigarettes of depressive symptomatology in heavy smokers, in per day were men. This is consistent with review reports.2,41 Smoking and minimal–mild depressive symptomatology in heavy smokers These results highlight the need for simultaneous 2. Secretaría de Salud, Instituto Nacional de Estadística, Geografía e Infor- treatments for smoking cessation and depression, mática. Encuesta Nacional de Adicciones 2002. México, DF: ConsejoNacional de Adicciones; 2002.
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